Dr Martei speaks with ecancer at AORTIC 2017 about access and affordability of medicines on the WHO Essential Medicines List.

Using the list as a guide, she describes how healthcare in Botswana compares to other African healthcare systems, with national essential medicines list providing alternative indicators for care provision.

Dr Martei highlights issues in stocking and procurement of medicines as endemic across global health systems, with cost being a particular concern for care in Botswana.

Looking forward, she describes how data from the Botswana Cancer Registry has been used to track and forecast drug cost and procurement, and to inform cost/benefit analyses around newer targeted drugs.

Transcript

I’m talking mainly about access to WHO essential medicines and so my main focus is looking at access and then also affordability of cancer medicines in sub-Saharan Africa as part of the steering committee for the WHO EML essential list that was submitted in 2016 and the most recent list that was published in 2017. My main research focus has really been in Botswana but some of the data can be extrapolated to other parts of Africa. What I’m trying to do now is actually start to quantify what the scope of access is. So we are looking at cancer medicines that are listed on the WHO Essential Medicines List which are really supposed to serve as a guide for a lot of national governments in terms of what disease areas to prioritise and what medicines to prioritise. So I’m using this list as a guide to figure out what is actually available to a patient with cancer being served in Botswana or any of these other African countries. So a lot of my research has really been trying to quantify that landscape.

What access issues are you seeing?

In Botswanta, for instance, Botswana is a unique situation, unlike a lot of African countries, where the Ministry of Health actually covers a lot of the cancer medicines on the WHO Essential Medicines List. So a lot of countries have what we call a National Essential Medicines List and this is really a list of medicines that the government actually covers, so proposes to cover. But then we realised that what’s actually available to patients doesn’t match up with what is on the list. So in Botswana there’s a huge alignment with the WHO Essential Medicines List, about 85% of the medicines on the WHO EML are actually on the National Essential Medicines List in Botswana. So if therapy was available in a sustainable form all cancer patients with most cancers on the WHO Essential Medicines List should be able to get it. But some of the issues that we’ve realised, something we call stock-out, which is really a descriptive term, we use for when a doctor intends to prescribe a medicine that a patient has consented for but it’s out of stock. Some of the issues that we’ve uncovered related to stock-out are issues with chemotherapy forecasting, so how do governments assess how much chemotherapy to buy, this is in terms of volumes, or how much it’s going to cost them to actually cover these chemotherapy agents.

There are also issues with supply chain procurement and so there are some inefficiencies in terms of how medicines are procured in the public sector as well. This is actually not just unique to Botswana but just in anecdotal data and also in recent surveys that have been conducted there are really inefficiencies with procurement that actually consistently affect how medicines become available to patients in Africa. So some people may be familiar with the issue of just the global shortage of certain medicines. In the cancer space there’s a global shortage of a lot of IV generic medicines and this happens mainly in developing countries actually. Some of the mechanisms that have been identified are lack of financial incentive, so actually producing these IV generics is no longer cost effective or it’s no longer financially lucrative to produce them. But in places like Botswana and other sub-Saharan African countries what we’ve realised is that although global shortages may affect some of these medicines’ availabilities, a lot of the issues are really related to cost and then also to supply chain mechanisms.

In countries unlike Botswana where patients actually have to pay out of pocket for medicines we find that these catastrophic costs of cancer medicines actually affect how accessible the medicines are for patients in most of sub-Saharan Africa actually.

How can this situation be changed?

That’s a really good question because that’s the next logical step is what can we do differently from what we are doing now. There are a lot of initiatives going on actually which is encouraging; the landscape is changing. So specifically for Botswana what we did was talk to pharmacy, the pharmacy team, and then also the essential medical procurement agency to figure out exactly how we can help with things like forecasting or improving the supply chain mechanism. What we realised for cancer is that cancer is actually really complex in terms of ordering medicines for different patients. So unlike the HIV epidemic in Botswana where it was relatively easy to figure out how much ARVs you’re going to need because there’s a certain denominator of HIV patients, then based on that denominator you figure out how many medicines you’re going to need, cancer care is a bit more complex. So the same medicine for breast cancer is dosed differently from Kaposi’s sarcoma, from Hodgkin’s.

So what we started to use was data from Botswana to figure out how much medicine you’re going to need. The priorities actually differ so if you see more cervical and more breast cancer patients then really your medicine procurement should reflect the numbers of these patients you’re actually seeing. It has to be methodological and systematic, I don’t think we can actually try to guess. So we used data from the Botswana National Cancer Registry to actually estimate how much chemotherapy is going to be needed in terms of volume, so the different number of vials of doxorubicin, cyclophosphamide. Then we further went on to actually, once we had the number of volumes, we could actually go on to then estimate the cost of chemotherapy.

It was really important actually to present that data to the Ministry of Health and it’s been important actually to see that data being used by different Ministries of Health at this conference as well. It was the first time that data was being presented to them on how much it actually costs the government to pay for these cancer medicines. So there’s a medicine like trastuzumab which is a targeted monoclonal antibody for a specific type of breast cancer called HER2 positive and in the past WHO has really included mainly generic medicines on the Essential Medicines List. But then in 2015 there was the introduction of the newer targeted therapies because it was thought that despite the cost of these drugs it was actually really effective. So the goal of putting it on the EML was to then act as a motivation to drive down prices, hopefully, of these drugs. Trastuzumab is still really expensive and so when we did our cost estimations what we realised was that even though the number of patients for whom this drug is indicated is less than 3%, it actually accounts for 43% of the budget. So it really tips the budget over and the reflex question was should we be covering this. I don’t think the answer is simple, I don’t think it’s no because it’s actually effective for those 3% of patients. These are patients who need the drug to be able to live longer; these are patients who need the drug for curative intent. But it was a process that hadn’t been done rigorously before and it formed the basis of really a formal process, at least in Botswana, where we start to analyse the cost benefit in a formal way in order to decide what should be covered on the Essential Medicines List. So should we be covering patients in the adjuvant setting, these are patients being treated for curative intent, or should we be covering all patients? These are some of the tough questions that we are starting to analyse.

Is there any funding for these drugs form anywhere apart from the central government?

Not in Botswana, in Botswana it’s all coming from the central government. They had some external funding with HIV but for cancer cure it’s all coming from the central government. In terms of what is happening in terms of increasing access there are different partnerships going on in other African countries now. So the Clinton Health Access Initiative, ACS and IBM are working on an initiative in six African countries to try to procure medicines at a much cheaper cost. But these medicines are intended to be purchased by the Ministries of Health as well but at a much cheaper negotiated cost. So this is something that’s going on as well.

There are a few initiatives here and there. It’s looking promising because it’s coming to the forefront that cancer is really an epidemic, a modern epidemic, in sub-Saharan Africa and the personnel and the resources for managing that are very inadequate at this time. But it’s come to global attention so there are initiatives that are going on and hopefully we can get a baseline assessment and then start to measure the impact and see if some of these interventions are scaleable.